Algorithms, critical pathways, and computer software for wound care: contemporary status and future potential.

The contemporary use of algorithms, critical pathways, and computer software significantly affects all aspects of healthcare treatment from primary care to acute trauma management. Guidelines and heuristic devices specific to chronic wound care have been introduced to assist with quality implementation and monitoring of outcomes in a cost-conscious American healthcare system. Some wound care algorithms and critical pathways even have been computerized. This article discusses the differences among the various forms of wound care heuristic methods, describes their advantages and disadvantages, and suggests how they can be successfully implemented in clinical practice settings. Directions for future research also are offered.

Chronic wound assessment.

Chronic wounds are a drain on health care resources, and as such, continue to challenge health care providers to define and create more effective intervention strategies. Wound assessment is the foundation for maintaining and evaluating a therapeutic plan of care. Without adequate baseline wound assessment and valid interpretation of the assessment data, the plan of care for the wound may be inappropriate or ineffective. This article discusses comprehensive assessment of the total patient as well as assessment of wound severity and wound status.

Senior centers. Shifting student paradigms.

The purpose of this study was to evaluate an innovative service learning experience for new nursing students involving senior citizen centers. Junior nursing students (n = 128) were assigned in cohorts to one of five centers for a 5-week rotation. A questionnaire was administered post hoc to the students, teaching assistants, center directors, and a sample of senior citizens at each site. The majority of students believed the experience was a valuable part of the curriculum and saw prospects for community health nursing roles. However, they had concerns regarding losing time in acute care and relevance and number of assignments, and reported some difficulty in applying classroom content in the setting. Directors and senior citizens were universally positive about the experience. Student and teaching assistant reports were key in revising the curriculum. Revisions include logistics of the placement of the experience and assignments as well as incorporation of this experience within the community context.

The Pressure Sore Status Tool a few thousand assessments later.

Although the Pressure Sore Status Tool (PSST) was developed using expert panelists and its reliability has been previously reported, the patterns that seem to be forming based on the first few thousand PSST assessments have not been reported yet. This paper will focus on analyses of a subset of PSST assessments that were collected as a by-product of testing a computerized assessment and decision support system. Changes in wound characteristics that appear to serve as "lead indicators" of healing, preliminary factor analysis data, and a correlation of total PSST scores with recorded stage will be discussed. Due to the sample size and variability within the data, it is premature to draw firm conclusions from the data. However, analyses of the first few thousand assessments and over 100 healed pressure ulcers show promise in confirming some prior speculations about wound healing. The data also appear to suggest the possibility of surprises that are not necessarily part of current understanding of wound healing in pressure ulcers.

The Wound Intelligence System: early issues and findings from multi-site tests.

The purpose of this manuscript is to address a gap in our efforts to incrementally improve wound care practice through evidence-based practice. The Pressure Sore Status Tool (PSST) provides data to extend evidence-based practice beyond clinical trials and into the clinical area itself. The computerized PSST was evaluated over one year through over 70 beta sites. Two studies which were part of that evaluation period are described which give a comparative analysis of wound stage and PSST scores, and similarities and differences in wound characteristics of four types of wounds: arterial/ischemic ulcers, neuropathic ulcers, pressure ulcers, and venous ulcers. In the first study, a relationship between PSST scores and staging scores for the presenting wound was present, indicating promise for the utilization of the PSST as an alternative to staging scores for describing changes in wound status. However, in the second study, clear difference was not noticeable between the four wound types, suggesting that discriminations regarding wound type may not be able to be made from PSST assessments. The goal of these studies was to provide feedback on the use of the computerized PSST, thereby providing feedback based on objective outcomes of the practice of clinicians themselves.

Wound care nurses' judgements on healing time in chronic wounds.

With the current push to develop critical pathways for chronic wound patients, information on "normal" versus problematic wound healing is important. This descriptive study begins to define chronic wound healing time markers by examining clinicians' own healing expectations with pressure ulcers. A 30-item questionnaire concerning partial and full thickness pressure ulcers on the sacrum, trochanter and heel was sent to 272 wound/ET nurses. Total response rate was 32.3% with 74 analyzable questionnaires returned. Data was analyzed using descriptive statistics and correlations where appropriate. Results were: (1) The longer respondents thought it would take for wounds to heal, the more variable their responses. (2) Respondents viewed heel wounds as taking the longest to heal and were more certain about time to healing in sacral wounds. (3) Responses indicated longer healing times than those shown in recent studies looking at change in wound surface area. (4) Results on time of 3.2 weeks to autolytic debridement of wounds with black eschar does not differ greatly from published time for enzymatic debridement, in spite of guidelines stating that autolysis may take longer than other methods. This study demonstrates that there remains variability in wound nurses' perceptions of time to healing and, therefore, recent attempts at defining critical pathways may be premature.

Toward an intelligent wound assessment system.

There is general agreement regarding the need for pressure ulcer assessment methodology which more discretely reflects relevant aspects of wound status than does the commonly used staging system. The Pressure Sore Status Tool (PSST) is one such instrument which was developed with consensual expert input. While the psychometric properties of the PSST have been reported in the literature, the instrument was validated using ET nurses, highly trained wound care specialists, and existed only in manual form. This paper reports results from attempts to establish reliability estimates for healthcare practitioners without extraordinary wound care training or experience. The paper further describes the automation of the PSST and provides examples of pressure ulcer profiles tracked over time. Results indicate that inter-rater reliability with general healthcare practitioners was .78 and intra-rater reliability was .89. The practitioners were able to use the PSST for over six months and the automated system allowed analysis of wound healing profiles that would have been difficult using a manual system. These results imply that movement toward an automated system which makes discriminations regarding the effects of various treatment and intervention strategies is possible and practical.

Predictors of successful prompted voiding among incontinent nursing home residents.

OBJECTIVE: To develop a simple, noninvasive assessment strategy that will enable nursing home staff to identify incontinent residents who respond well to prompted voiding. DESIGN: Incontinent nursing home residents underwent an extensive clinical and functional assessment and then 7 days of prompted voiding. Data from the assessment and the first 3 days of prompted voiding were used to predict responsiveness to the intervention. SETTING: Seven nursing homes. PATIENTS: A cohort of 191 incontinent, long-stay nursing home residents who passed a simple behavioral screen (able to state their name or reliably point to one of two named objects). INTERVENTION: Prompted voiding was carried out by trained research nurse's aides from 7 AM to 7 PM for 7 days. The intervention was maintained in responsive residents 5 days per week for an additional 9 weeks. MAIN OUTCOME MEASURES: Physical checks for wetness were done by research staff hourly from 7 AM to 7 PM for 3 days in a baseline condition, during days 5 through 7 of the 7-day prompted voiding intervention, and for 3 days at the end of 9 weeks of prompted voiding in the responsive group. Outcome measures were percentage of checks wet and response to prompted voiding, with "responders" defined as residents with an average of one or fewer wet episode per day on days 5 through 7 of prompted voiding. RESULTS: Seventy-eight (41%) of the residents were responders. Their wet percentage went from 26.7% to 6.4% at the end of 1 week and was maintained at 9.6% after 9 weeks of prompted voiding. The best predictors of responsiveness were the wet percentage and the appropriate toileting percentage during the first 3 days of prompted voiding, the self-care subscale score of the Multidimensional Observational Scale for the Elderly, and the ability to ambulate without human assistance. The best sensitivity and specificity in identifying responders was achieved when either the wet percentage was lower than 20% or the appropriate toileting percentage was higher than 66% during the first 3 days of prompted voiding (sensitivity, 87%; specificity, 69%). Those residents falsely identified as responders by these criteria still had a 46% relative reduction in wetness. CONCLUSIONS: A substantial proportion of nursing home residents respond well to prompted voiding. The most responsive residents can be easily identified using data collected during a 3-day trial of the intervention. The assessment strategy is consistent with federal guidelines and could be used to facilitate quality control by assessing changes in percentage of wetness from the expected norm.

Use of a portable ultrasound device to measure post-void residual volume among incontinent nursing home residents.

OBJECTIVE: To determine the accuracy of a portable ultrasound device for the assessment of post-void residual (PVR) volume among incontinent nursing home (NH) residents. DESIGN: Prospective, clinical series. SETTING: Seven community-based nursing homes. STUDY POPULATION: Two hundred one consecutively assessed incontinent NH residents who were participating in a larger clinical trial. MEASUREMENTS: PVR volumes measured by trained research associates using a portable ultrasound device and by in-and-out catheterization were compared. The accuracy of the ultrasound was calculated using the volume obtained by catheterization as the gold standard. RESULTS: The ultrasound demonstrated excellent test-retest and interrater reliability. For low PVRs, the device was highly sensitive (.90) for PVR < 50 mL and .95 for PVR < 100 mL) and moderately specific (.71 for PVR < 50 mL and .63 for PVR < 100 mL). For PVRs of more than 200 mL (n = 26), the ultrasound had a sensitivity of .69 and a specificity of .99. CONCLUSION: The portable ultrasound we used was reliable and reasonably accurate for assessing PVR in a representative sample of incontinent NH residents. Because the sensitivity for clinically significant urinary retention (PVR > 200 mL) was only .69, repeated measurements may be necessary to exclude high PVR in individual NH residents. Recent changes in ultrasound design should improve its ease of use and accuracy. Although measuring PVR by ultrasound is much easier and more comfortable than catheterization for both NH residents and staff, the cost of the device may be a barrier to its widespread use in the NH setting.

The dark side of incontinence: nighttime incontinence in nursing home residents.

OBJECTIVE: To describe the characteristics of nighttime urinary incontinence in a sample of nursing home (NH) residents. DESIGN: Prospective descriptive study of a convenience sample of incontinent NH residents. SETTING: Four NHs. PARTICIPANTS: 136 incontinent NH residents. MEASUREMENTS: Frequency and volume of incontinent and continent voids for three 10-hour daytime and three 10-hour nighttime data collection periods. RESULTS: The frequency of nighttime incontinence was the same as during the day, but the volume of nighttime incontinent voids and total nighttime volume were higher than during the day. There was substantial between- and within-subject variability in volumes, but the distribution of ratios of night/total volumes approximated a normal curve. Diuretic use was associated with relatively low nighttime volumes. CONCLUSION: About one-quarter of the NH residents we studied produced substantially more urine at night than during the day. Several medical, behavioral, and environmental approaches should be considered for reducing the frequency and volume of nighttime incontinence in this population.

Validity and reliability of the Pressure Sore Status Tool.

There is not yet a universal system for describing the status of pressure sores. The purpose of this study was to assess the validity and reliability of an instrument developed by the researchers for evaluation of pressure sores, the Pressure Sore Status Tool (PSST). This study was part of a larger study, which included development of a theoretical model for creation of items for the PSST. A nine-member expert judge panel established content validity of items on the instrument. Data were analyzed using a content of validity index (average index for tool = .91) and judges' comments were used to modify two items on the PSST. Two Enterostomal Therapy (ET) nurses independently used the revised tool to rate 20 pressure sores on ten adult medical-surgical patients, at two observation times. Interrater reliability was established at r = .91 for first observation and r = .92 for the second observation (p < .001). Intrarater reliability was r = .99 for rater one and r = .96 for rater two (p < .001). Future research will focus on refinement and further reliability testing of the instrument.

Psychological response to illness: exploring two reactions to ostomy surgery.

This paper has discussed two psychological responses to ostomy surgery, denial and personal control, both of which can be maladaptive in situations faced by ostomy patients. Nursing interventions for each response were suggested and discussed in relation to two case studies. It is hoped the the information presented will be useful to nurses dealing with persons undergoing ostomy surgery and experiencing maladaptive behavior.